Newspaper/Magazine Article

Workarounds are prevalent in health care and create opportunities for unintended consequences. This newsletter article discusses how workarounds serve as indicators of system failures and present opportunities to identify and design long-term strategies to reduce risks.

Tools/Toolkit > Government Resource

Rockville, MD: Agency for Healthcare Research and Quality; April 2016.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This toolkit provides resources to help organizations implement TeamSTEPPS in the office-based setting, including information about how to create a handoff checklist and when to have a huddle along with the benefits of using one. The material also includes an instructor guide and training videos.

Adverse events are thought to be common in patients receiving home health care. This systematic review defined home care safety risks for both patients and caregivers, including awkward working positions, social distractions, abuse and violence, and other issues that are relatively unique to this care setting.

Web Resource > Course Material/Curriculum

Rockville, MD: Agency for Healthcare Research and Quality; September 2015.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This curriculum offers training for participants to implement TeamSTEPPS in their organizations. The course includes evidence reviews, trainer guidance, measurement tools, and a pocket guide for frontline staff.

Book/Report

This revised and reorganized book provides a primer on how human error causes mishaps and often illustrates deeper troubles within a system. Both the old view of human error that places blame on the individual and the new view that identifies most human failures as merely a symptom of systems-level problems are presented. This view of human error has led to the application of root cause analyses and human factors engineering in health care. New chapters discuss the importance of safety culture and provide recommendations on improving the failure investigation process.

Book/Report

The value of current measures to track patient safety has been called into question. This technical report provides information about a consensus-driven initiative to evaluate the reliability of existing patient safety measures in tracking and assessing safety in hospitals, across various populations and settings. The related website offers resources related to the project history.

Journal Article > Commentary

High reliability organizations learn from experience. To promote learning and improve health care safety in the United Kingdom, this commentary recommends establishing an independent center dedicated to coordinating investigations into medical errors and system failures that would draw from other high-risk industries practices and provide guidance to organizations seeking to apply this model.

High-reliability organizations like the aviation industry have developed methods for achieving safety despite hazardous conditions. This commentary describes obstacles to utilizing process improvement techniques from industry in health care—such as skepticism about the applicability of the methods to frontline practice—and relates strategies to understand and address these barriers.

Diagnostic errors are a common cause of patient harm in ambulatory care. Although such errors have often been ascribed to cognitive biases, this study highlights physicians' concerns that health system structures and communication are major drivers of delayed and missed diagnoses. Focus group discussions involving 25 outpatient physicians—primarily from internal and family medicine—identified multiple potential sources of diagnostic errors, including insufficient information availability, disjointed workflows, and poor communication among providers and with patients. This study underscores many overlapping issues that will need to be addressed to meaningfully enhance diagnostic accuracy. In a recent AHRQ WebM&M interview, Dr. Urmimala Sarkar, the lead author of this study, discussed patient safety in the ambulatory setting.

Journal Article > Commentary

This commentary describes the development and implementation of a daily group phone call, guided by a unit leader, to facilitate discussion about patient safety concerns across a health system. The authors review the results and lessons learned in the 4 years following the intervention.

Newspaper/Magazine Article

Language barriers can lead to misunderstandings that increase risks of error. This magazine article highlights the frequent reliance on families, friends, and other nonprofessionals as translators in medical settings and discusses how lack of standards and insufficient reporting of errors related to interpreters, along with challenges to implementing programs, hinder progress in improving communication with non-English speaking patients.

Journal Article > Study

This single-hospital study explored the practice of medication dispensing by physicians. Although physicians were commonly expected to dispense medications, especially in the emergency department, some participants felt insufficiently trained to perform this task.

Journal Article > Commentary

This commentary highlights cultural factors that contribute to organizational silence in academic health centers, such as rigid professional structures, time pressures, and hierarchy. The authors offer recommendations to address this issue, including developing faculty members as leaders committed to change and training mentors to teach colleagues conversation skills to enable them speak up and discuss concerns.

Journal Article > Commentary

The Clinical Learning Environment Review (CLER) program was developed to evaluate the performance of teaching institutions in six key areas that affect patient outcomes. This commentary describes how poor safety culture in clinical practice can counteract the effect of educating medical students about quality and safety principles. The authors note unintended consequences of the CLER program and strategies to avoid them.

Journal Article > Study

This cross-sectional study found that reports of nurses' safety organizing, behaviors meant to identify and address errors, were associated with decreased turnover and less emotional exhaustion, adding to the evidence for fostering a positive safety culture.

Journal Article > Study

Examining concerns about resident duty-hours restrictions in Canada, this interview study found that gaps in clinical care resulting from decreased resident hours were prevalent, particularly in inpatient settings. These findings mirror prior studies in the United States.

Book/Report

This book covers two perspectives of safety: a reactive approach that emphasizes reducing adverse outcomes and a proactive approach that focuses on ensuring actions go as planned. The author discusses how each approach has been applied in health care and other high-risk industries.

This study surveyed nurse managers to evaluate the implementation of pre-surgical briefings and post-surgical debriefings recommended by the World Health Organization's Safe Surgery program. Researchers found that practices were variably sustained and team training appeared to augment implementation.